Apparatus and method for managing prescription benefits

ABSTRACT

A system and method are disclosed for managing prescription benefits. Case records containing information regarding patients and prescription coverage activities for the patients are stored in the system. Users are allowed access to the system via an appropriate electronic communication network. The user can subsequently perform various tasks in order to maintain and review coverage activities. The user can also enter additional prescription coverage activities into the case records, as well as verify that information entered into the case records has been updated.

RELATED APPLICATIONS

This application is a Continuation of U.S. patent application Ser. No.11/635,714, filed Dec. 7, 2006, now U.S. Pat. No. 7,774,213, issued Aug.10, 2010, which is a Divisional of U.S. patent application Ser. No.10/334,981, filed Jan. 2, 2003, now U.S. Pat. No. 7,155,397, issued Dec.26, 2006 which claims the priority of U.S. Provisional Application No.60/349,352 filed Jan. 22, 2002, all of which are incorporated herein byreference.

BACKGROUND OF THE INVENTION

1. Technical Field

The present invention relates to prescription benefits and, moreparticularly, to a method and system for managing prescription benefitscoverage.

2. Description of the Related Art

Various employers offer healthcare coverage to their employees. Thehealthcare coverage will typically include the cost of prescriptiondrugs (or products), in whole or in part. The healthcare coverage canalso cover the cost of certain treatments. The type of prescriptioncoverage offered to the employee can vary depending on the particularhealthcare provider selected by the employer. The specific coverageoffered to an employee can depend on several factors, including theparticular coverage program negotiated by the employer. For example, thebenefits available can be different depending on the medical coveragedesired, the prescription medication available, etc. Furthermore, thespecific benefits requested will directly effect the coverage cost.

Regardless of the coverage, the healthcare provider will place certainrestrictions and/or limitations on the prescription medicationavailable. These restrictions determine whether the healthcare providerwill cover the cost of a prescription claim in full or in part. Forexample, the healthcare provider may cover the cost of a prescriptionclaim in full, if the employee is willing to substitute a generic formof the prescribed medication. The cost of the prescription can besubsidized to different degrees, depending on the type of coverage, forexample, if the employee prefers to use a brand name form of themedication.

Oftentimes, the healthcare provider will negotiate actual medicationcosts with one or more pharmaceutical companies in order to arrive at acoverage plan which best satisfies the budgetary requirements of theemployer. For example, depending on the size of the healthcare provideror employer, various discounts can be allowed if a certain number ofpatients subscribe to the plan. Costs can be controlled by substitutinggeneric forms of a drug (i.e., product) in place of name brand form.Costs can also be controlled based on the drug (i.e., product) used totreat a particular disease or condition.

Implementation of a healthcare coverage plan requires administrativeprocedures to address circumstances when a patient requires specializedtreatment and/or medication. While such treatments may be supported bythe coverage plan, the extent of coverage may be limited due to, forexample, a very low rate of occurrence. Healthcare providers can conductnegotiations with employers in order to reach an agreement on how thecoverage plan will address these special circumstances. Thesenegotiations can often include guidelines for dealing with coverage ofspecial medication and/or treatment not desired by the employer due to,for example, higher costs. For example, the coverage plan can requirethat a patient seek alternative forms of treatment prior to obtainingcoverage for a specialized medical procedure. The patient may alsoreceive coverage for certain types of drugs (i.e., products) only ifalternative drugs have been tried unsuccessfully.

Healthcare coverage plans must also provide patients with an avenue fordispute resolution/mediation of claim denials for coverage of treatmentsand medications (e.g., coverage denials), whether basic or specialized.This can be in the faun of an appeal or review process which examinesthe underlying circumstances for denying coverage of the treatmentand/or medication. The specific details for dispute resolution andmediation must also be negotiated between the employer and healthcareprovider as part of the coverage plan.

Healthcare providers can face difficulties in managing coverage plansdepending on various factors. For example, a healthcare provider mayrender services to a number of employers, each of whom must offercoverage to multiple patients. The number of patients can vary, ofcourse, based on the size of the employer and availability ofalternative coverage plans (e.g., alternative healthcare providers). Inthe case of a large employer with few alternative coverage plans, thehealthcare provider may be responsible for managing benefits of a greatdeal of patients. This situation is further complicated if thehealthcare provider extends coverage plans to additional largeemployers.

When claims are received by the healthcare provider, they must bereviewed to ensure that they are supported by the patient's coverageplan. In the case of prescriptions, immediate approval or denial isrequired while the pharmacist prepares the prescription. It can bedifficult to quickly approve or deny the prescription if the patient'sprescription plan includes a large number of restrictions. Furthercomplications arise when the patient requires specialized medication. Itis possible to mistakenly support the prescription claim through thecoverage plan if a restriction is overlooked. It is also possible tomistakenly deny the prescription claim if a restriction ismisinterpreted.

Both situations can prove costly over time. For example, if prescriptionclaims are mistakenly supported, the healthcare provider must absorb theloss rather than bill the client for the cost of covering theprescription claim. On the other hand, if prescriptions are mistakenlydenied, clients may become dissatisfied and seek another healthcareprovider. Consequently, healthcare providers must exercise care inmanaging the different coverage plans under their control.

The result of these negotiations is a comprehensive set of treatment andmedication coverage rules. The coverage rules define the terms and/orconditions for approving, denying, and appealing coverage of basic andspecialized treatment and medications. The coverage rules can beextensive and often must be converted into electronic form to assist inadministration of the coverage plan.

Accordingly, there exists a need for a prescription benefits managementsystem that addresses at least some of the current shortcomings ofexisting systems.

There also exists a need for a prescription benefits management systemthat allow healthcare providers to easily and efficiently managemultiple healthcare coverage plans.

There exists another need for a prescription benefits management systemthat minimizes the number and costs of errors associated with processingprescription claims.

There exists a further need for a prescription benefits managementsystem that optimizes the medications and treatments available topatents.

There exists a still further need for a prescription benefits managementsystem that optimizes the cost paid by patients to obtain prescriptioncoverage.

SUMMARY OF THE INVENTION

It is therefore one feature and advantage of the present invention toaddress at least some of the shortcomings of the prior art in managingprescription benefits.

It is another optional feature and advantage of the present invention toprovide a prescription benefits management system capable of allowingmanagement of multiple healthcare coverage plans.

It is yet another optional feature and advantage of the presentinvention to provide a prescription benefits management system capableof minimizing the number of errors associated with processingprescription claims.

It is a further optional feature and advantage of the present inventionto provide a prescription benefits management system capable ofoptimizing the medications and treatments available to patients.

It is a still further optional feature and advantage of the presentinvention to provide a prescription benefits management system ofoptimizing the cost paid by patients to obtain prescription coverage.

The foregoing, and various other needs, are addressed, at least in part,by the present invention, wherein a benefits management system allowscase records to be managed, searched, and modified quickly andefficiently from central location.

According to one embodiment of the invention, a method is provided formanaging prescription benefits using a prescription benefit managementsystem. The method comprising the steps: accessing a case recordcontaining information regarding a patient and prescription coverageactivities for the patient; conducting an inquiry on the case record toview and/or review selected prescription coverage activities containedin the case record; inputting additional prescription coverageactivities into the case record, if necessary; verifying that the caserecord has been updated, if additional prescription coverage activitieswill not be inputted; and closing the case record. According to such amethod, multiple prescription benefits coverage plans can be easily andefficiently managed in order to optimize the cost of service topatients. Furthermore, the range of treatments (or medications)available to patients can be increased.

According to certain optional aspects of the invention, users can obtainvarious instructional and informative information while using theprescription benefits management system. More particularly, users caneasily obtain help documentation regarding certain topics while usingthe system. Actual technical and reference manuals are also availablefor access while using the system. Status reports can also be obtainedto identify various reasons why a claim for prescription coverage mayhave been approved or denied. Users can also access a reference librarycontaining documents used to support decisions, such as a prescriptioncoverage denial.

According to another optional embodiment of the invention, certain userscan access case records that are currently open and release (or close)such case records. For example, a case record being viewed by a user canbe opened by a special user. Next, the special user can release the caserecord without the user's authorization. Such a feature can allowadministrative personnel to modify and/or update case records withoutthe need to wait for users to finish accessing those case records.Furthermore, such a feature can assist in maintaining case recordsstored in the prescription benefits management system. For example,there are situations where case records may be inadvertently left openor otherwise become inaccessible. An administrative personnel, forexample, could access and close the case record, thereby making itavailable for use by other users.

According to another optional embodiment of the present invention, userscan view the reasons used to deny a prescription coverage, including anyspecific details pertaining to the denial. Administrators can reviewsuch denials and impose an override based on various clinical criteria.Users can also process appeals received for denial of a prescriptioncoverage, and subsequently reverse the denial. As part of the reversal,an original prescription product can optionally be replaced by asubstitute product which has the same benefits of the original product,but is covered under the patients prescription benefits program.

According to another aspect of the invention, an arrangement system formanaging prescription benefits comprises a prescription benefitsmanagement system, a communication device, and a user computer. Theprescription benefits management system stores a plurality of caserecords that contain information regarding patients and prescriptioncoverage activities for the patient. The communication device is coupledto the prescription benefits management system for providing access tousers over one or more electronic communication networks. A user iscapable of utilizing the user computer to access the prescriptionbenefits management system from a remote location. The prescriptionbenefits management system further allows users to: conduct an inquiryon the case records to view and/or review selected prescription coverageactivities contained in the case record; input additional prescriptioncoverage activities into the case records, if necessary; verify that thecase records have been updated, if additional prescription coverageactivities will not be inputted; and close the case records. Accordingto such an arrangement, prescription benefits coverage plans can beeasily and efficiently managed in order to optimize the cost of serviceto patients. Furthermore, the range of treatments (or medications)available to patients can be increased.

There has thus been outlined, rather broadly, the more importantfeatures of the invention and several, but not all, embodiments in orderthat the detailed description thereof that follows may be betterunderstood, and in order that the present contribution to the art may bebetter appreciated. There are, of course, additional features of theinvention that will be described hereinafter and which will form thesubject matter of the claims appended hereto.

In this respect, before explaining at least one embodiment of theinvention in detail, it is to be understood that the invention is notlimited in its application to the details of construction and to thearrangements of the components set forth in the following description orillustrated in the drawings. The invention is capable of otherembodiments and of being practiced and carried out in various ways.Also, it is to be understood that the phraseology and terminologyemployed herein are for the purpose of description and should not beregarded as limiting.

As such, those skilled in the art will appreciate that the conception,upon which this disclosure is based, may readily be utilized as a basisfor the designing of other structures, methods and systems for carryingout the several purposes of the present invention. It is important,therefore, that the claims be regarded as including such equivalentconstructions insofar as they do not depart from the spirit and scope ofthe present invention.

Further, the purpose of the foregoing abstract is to enable the U.S.Patent and Trademark Office and the public generally, and especially thescientists, engineers and practitioners in the art who are not familiarwith patent or legal terms or phraseology, to determine quickly from acursory inspection the nature and essence of the technical disclosure ofthe application. The abstract is neither intended to define theinvention of the application, which is measured by the claims, nor is itintended to be limiting as to the scope of the invention in any way.

These, together with other objects of the invention, along with thevarious features of novelty which characterize the invention, arepointed out with particularity in the claims annexed to and forming apart of this disclosure. For a better understanding of the invention,its operating advantages and the specific objects attained by its uses,reference should be had to the accompanying drawings and descriptivematter in which there is illustrated preferred embodiments of theinvention.

BRIEF DESCRIPTION OF THE DRAWINGS

FIG. 1 is a block diagram illustrating a hierarchical menu layout of aprescription benefits management system according to an exemplaryembodiment of the present invention;

FIG. 2 is a flow chart illustrating the steps performed when authorizingaccess to the prescription benefits management system;

FIG. 3 is a flow chart illustrating the steps performed to obtainassistance in using the prescription benefits management system;

FIG. 4 is a flow chart illustrating the steps performed to release acase currently being held;

FIG. 5 is a flow chart illustrating the steps performed when conductinga search for case records;

FIG. 6 is a flow chart illustrating the steps performed when the detailsof a case must be viewed;

FIG. 7 is a flow chart illustrating the steps performed when reviewingthe history of communications for a case;

FIG. 8 is a flow chart illustrating the steps performed when reviewingthe coverage criteria for a prescription;

FIG. 9 is a flow chart illustrating the steps performed to review thestatus of a case;

FIG. 10 is a block diagram illustrate exemplary functions accessiblefrom an administrative menu;

FIG. 11 illustrates an arrangement for managing prescription benefitsaccording to an exemplary embodiment of the invention; and

FIG. 12 is a block diagram illustrating an exemplary computer system forimplementing an embodiment of the prescription benefits managementsystem.

DETAILED DESCRIPTION OF THE INVENTION

Reference now will be made in detail to the presently preferredembodiments of the invention. Such embodiments are provided by way ofexplanation of the invention, which is not intended to be limitedthereto. In fact, those of ordinary skill in the art may appreciate uponreading the present specification and viewing the present drawings thatvarious modifications and variations can be made.

For example, features illustrated or described as part of one embodimentcan be used on other embodiments to yield a still further embodiment.Additionally, certain features may be interchanged with similar devicesor features not mentioned yet which perform the same or similarfunctions. It is therefore intended that such modifications andvariations are included within the totality of the present invention.

Prior to describing the details of the invention, a brief discussion ofsome of the notations and nomenclature used in the description will bepresented. Next, a description of exemplary hardware useable inpracticing the invention will be presented.

Notations and Nomenclature

The detailed descriptions which follow may be presented in terms ofprogram procedures executed on a computer or network of computers. Theseprocedural descriptions and representations are the means used by thoseskilled in the art to most effectively convey the substance of theirwork to others skilled in the art.

A procedure is here, and generally, conceived to be a self-consistentsequence of steps leading to a desired result. These steps are thoserequiring physical manipulations of physical quantities. Usually, thoughnot necessarily, these quantities take the form of electrical ormagnetic signals capable of being stored, transferred, combined,compared and otherwise manipulated. It proves convenient at times,principally for reasons of common usage, to refer to these signals asbits, values, elements, symbols, characters, terms, numbers, or thelike. It should be noted, however, that all of these and similar termsare to be associated with the appropriate physical quantities and aremerely convenient labels applied to these quantities.

Further, the manipulations performed are often referred to in teems,such as adding or comparing, which are commonly associated with mentaloperations performed by a human operator. No such capability of a humanoperator is necessary, or desirable in most cases, in any of theoperations described herein which faun part of the present invention;the operations are preferably machine operations, although theoperations may also be manual in alternative embodiments. Usefulmachines for performing the operation of the present invention includegeneral purpose digital computers or similar devices.

The present invention also relates to apparatus for performing theseoperations. This apparatus may be specially constructed for the requiredpurpose or it may include a general purpose computer as selectivelyactivated or reconfigured by a computer program stored in the computer.The procedures presented herein are not inherently related to aparticular computer or other apparatus. Various general purpose machinesmay be used with programs written in accordance with the teachingsherein, or it may prove more convenient to construct more specializedapparatus to perform the required method steps. Alternatively, one ormore of the steps may be performed manually. The required structure fora variety of these machines will appear from the description given.

Hardware Overview

FIG. 12 is a block diagram that illustrates a computer system 200 uponwhich an embodiment of the invention may be implemented. Computer system200 includes a bus 202 or other communication mechanism forcommunicating information, and a processor 204 coupled with bus 202 forprocessing information. Computer system 200 also includes a main memory206, such as a random access memory (RAM) or other dynamic storagedevice, coupled to bus 202 for storing information and instructions tobe executed by processor 204. Main memory 206 also may be used forstoring temporary variables or other intermediate information duringexecution of instructions to be executed by processor 204. Computersystem 200 further includes a read only memory (ROM) 208 or other staticstorage device coupled to bus 202 for storing static information andinstructions for processor 204. A storage device 210, such as a magneticdisk or optical disk, is provided and coupled to bus 202 for storinginformation and instructions.

Computer system 200 may be coupled via bus 202 to a display 212, such asa cathode ray tube (CRT), for displaying information to a computer user.An input device 214, including alphanumeric and other keys, is coupledto bus 202 for communicating information and command selections toprocessor 204. Another type of user input device is cursor control 216,such as a mouse, a trackball, or cursor direction keys for communicatingdirection information and command selections to processor 204 and forcontrolling cursor movement on display 212. This input device typicallyhas two degrees of freedom in two axes, a first axis (e.g., x) and asecond axis (e.g., y), that allows the device to specify positions in aplane.

The invention is related to the use of computer system 200 for managingprescription benefits. According to one embodiment of the invention,managing prescription benefits is provided by computer system 200 inresponse to processor 204 executing one or more sequences of one or moreinstructions contained in main memory 206. Such instructions may be readinto main memory 206 from another computer-readable medium, such asstorage device 210. Execution of the sequences of instructions containedin main memory 206 causes processor 204 to perform the process stepsdescribed herein. One or more processors in a multi-processingarrangement may also be employed to execute the sequences ofinstructions contained in main memory 206. In alternative embodiments,hard-wired circuitry may be used in place of or in combination withsoftware instructions to implement the invention. Thus, embodiments ofthe invention are not limited to any specific combination of hardwarecircuitry and software.

The term “computer-readable medium” as used herein refers to any mediumthat participates in providing instructions to processor 204 forexecution. Such a medium may take many forms, including but not limitedto, non-volatile media, volatile media, and transmission media.Non-volatile media include, for example, optical or magnetic disks, suchas storage device 210. Volatile media include dynamic memory, such asmain memory 206. Transmission media include coaxial cables, copper wireand fiber optics, including the wires that comprise bus 202.Transmission media can also take the form of acoustic or light waves,such as those generated during radio frequency (RF) and infrared (IR)data communications. Common forms of computer-readable media include,for example, a floppy disk, a flexible disk, hard disk, magnetic tape,any other magnetic medium, a CD-ROM, DVD, any other optical medium,punch cards, paper tape, any other physical medium with patterns ofholes, a RAM, a PROM, and EPROM, a FLASH-EPROM, any other memory chip orcartridge, a carrier wave as described hereinafter, or any other mediumfrom which a computer can read.

Various forms of computer readable media may be involved in carrying oneor more sequences of one or more instructions to processor 204 forexecution. For example, the instructions may initially be borne on amagnetic disk of a remote computer. The remote computer can load theinstructions into its dynamic memory and send the instructions over atelephone line using a modem. A modem local to computer system 200 canreceive the data on the telephone line and use an infrared transmitterto convert the data to an infrared signal. An infrared detector coupledto bus 202 can receive the data carried in the infrared signal and placethe data on bus 202. Bus 202 carries the data to main memory 206, fromwhich processor 204 retrieves and executes the instructions. Theinstructions received by main memory 206 may optionally be stored onstorage device 210 either before or after execution by processor 204.

Computer system 200 also includes a communication interface 218 coupledto bus 202. Communication interface 218 provides a two-way datacommunication coupling to a network link 220 that is connected to alocal network 222. For example, communication interface 218 may be anintegrated services digital network (ISDN) card or a modem to provide adata communication connection to a corresponding type of telephone line.As another example, communication interface 218 may be a local areanetwork (LAN) card to provide a data communication connection to acompatible LAN. Wireless links may also be implemented. In any suchimplementation, communication interface 218 sends and receiveselectrical, electromagnetic or optical signals that carry digital datastreams representing various types of information.

Network link 220 typically provides data communication through one ormore networks to other data devices. For example, network link 220 mayprovide a connection through local network 222 to a host computer 224 orto data equipment operated by an Internet Service Provider (ISP) 226.ISP 226 in turn provides data communication services through theworldwide packet data communication network, now commonly referred to asthe “Internet” 228. Local network 222 and Internet 228 both useelectrical, electromagnetic or optical signals that carry digital datastreams. The signals through the various networks and the signals onnetwork link 220 and through communication interface 218, which carrythe digital data to and from computer system 200, are exemplary forms ofcarrier waves transporting the information.

Computer system 200 can send messages and receive data, includingprogram code, through the network(s), network link 220, andcommunication interface 218. In the Internet example, a server 230 mighttransmit a requested code for an application program through Internet228, ISP 226, local network 222 and communication interface 218. Inaccordance with the invention, one such downloaded application providesfor managing prescription benefits as described herein. The receivedcode may be executed by processor 204 as it is received, and/or storedin storage device 210, or other non-volatile storage for laterexecution. In this manner, computer system 200 may obtain applicationcode in the form of a carrier wave.

Prescription Benefits Management System

Turning now to the drawings and initially to FIG. 1, a block diagram isshown for illustrating a menu hierarchy of a prescription benefitsmanagement system 100 in accordance with an exemplary embodiment of thepresent invention. The prescription benefits management system 100 isdesigned to provide users an ability to conveniently manage andimplement a prescription benefits program. These abilities include, butare not limited to: browsing coverage related information, aggregatingcoverage activities summary, administering appeal procedures, andgenerating related correspondences. The prescription benefits managementsystem 100 is also capable of administering coverage reviews andgenerating related correspondence; tracking and managingcontacts/communications with members (e.g., employers), physicians, andpharmacist; and creating and maintaining coverage criteria.

The prescription benefits management system 100 can be remotely accessedby various users including, but not limited to, patients, clients (e.g.employers, healthcare providers, etc.), and administrators in order toobtain and review information regarding their prescription benefitprogram. Access can be provided, for example, using an appropriatecommunication interface 218 and/or device, as discussed with respect toFIG. 12. For example appropriate network connectors and/or high speedcommunication devices (cable modem, DSL modem, satellite data transfer,etc.) can be used in conjunction with an ISP 226 to establish theconnection.

The prescription benefits management system 100 provides support tohealthcare administrators in processing pharmaceutically relatedcoverage review and/or appeals by providing real-time access to coverageinformation for members. For example, the coverage information caninclude the coverage criteria, case activity, reasons for denial, etc.The prescription benefits management system 100 can be configured as arules-based Coverage Management Workstation (CMWS) for easilyimplementing, modifying, and utilizing prescription benefit programs formultiple clients (or employers).

As illustrated in FIG. 1, the prescription benefits management system100 presents the user a hierarchical menu system that allows the user toaccess various information and perform tasks necessary to properlymanage the prescription benefits of a client. Furthermore, the clientcan also access the prescription benefits management system 100 in orderto obtain and/or review information pertaining to its account. AlthoughFIG. 1 illustrates specific menus and transactions that can be accessed,it should be noted that the prescription benefits management system 100can also include various other menus and transactions. The specificimplementation of the system, as well as client needs, will determinethe exact menu layout to be used. For example, the prescription benefitsmanagement system 100 can include menus for performing any and all tasksrelated to management of prescription benefits. Furthermore, alternativeembodiments of the prescription benefits management system 100 caninclude different menu layouts that allow users to more efficientlyperform the tasks necessary to manage a client's prescription benefits.

According to the exemplary hierarchy, the prescription benefitsmanagement system 100 provides users with an initial login screen 110.The login screen 110 can be used, for example to request ausername/password combination, an account/password combination, etc. Thelogin screen 110 is used, in part, to verify that the user is authorizedto access the prescription benefits management system 100. This isparticularly significant in embodiments of the prescription benefitsmanagement system 100 that allow remote access through open, or public,networks. More particularly, the prescription benefits management system100 can be assessed in several ways. Users can access the system throughprivate, or local area networks (LANs) that provide a different level ofsecurity because all users are internal users (e.g. employers) of acompany. However, certain embodiments can allow access by external usersthrough public networks such as the Internet and/or World Wide Web(WWW). In such instances, authentication is important because amalicious user can attempt to gain unauthorized access. Once access isgained, such a user can change, modify, or possibly destroy recordsand/or other data stored on the prescription benefits management system100.

The login screen 110 can also be used to automatically establish accessrights to certain users. For example, an administrative user may havedesignated authority to change, modify, or create information stored onthe prescription benefits management system 100. A staff member (e.g., acustomer service representative) may have the authority to view, change,or modify data without being able to create new records. A client orpatient accessing the prescription benefits management system 100 mayonly have the authority to view information, respond to questions,and/or enter data into forms. Again, such access rights can varydepending on the specific implementation of the prescription benefitsmanagement system 100.

Upon successful login to the prescription benefits management system100, the user is presented with a main menu 112. The main menu 112 canbe presented through a graphical interface that includes icons, menus,buttons, etc. representative of available options. The user could makeselections using an available cursor control device 216 (illustrated inFIG. 12), as previously discussed. Alternatively, the main menu 112 canbe presented to the user through a text, or non-graphical, interface.The user would then use various combinations of keystrokes from theinput device 214 to make the proper selection.

According to the embodiment of the prescription benefits managementsystem 100 illustrated in FIG. 1, the main menu 112 provides the userwith five menu (or submenu) options. Namely, the user has an option toview help and user manuals 114, obtain a status report 116, view areference library 118, release a case 120, or search for one or morecases 122. As previously discussed, other options may be provideddepending on implementation and client needs.

The view help and user manuals menu 114 provides the user access tovarious documentation to assist in operating the prescription benefitsmanagement system 100. When the user accesses this menu, they can bepresented with additional submenus that require input specific foraccessing user manuals or help manual. The help manuals can be in theform of context-sensitive on-line documents. In addition, the helpmanuals can be in the form of individual pages that contain descriptivetext on certain components of the prescription benefits managementsystem 100. The help manuals could be used, for example, to provide anoverview or assistance with the prescription benefits management system100, and would not be intended to provide detailed and/or technicalinformation regarding the prescription benefits management system 100.According to one embodiment of the present invention, the view help anduser manuals menu 114 can be accessed from any menu level (e.g.,accessible from every menu presented) in the prescription benefitsmanagement system 100. Accordingly, a user could always seek assistance.In addition, the pages of the help manual can include descriptive textabout the menu, or page, from which the user requested help.

According to the illustrated embodiment of the invention, the usermanuals are electronic versions of the actual manuals/documentation forthe prescription benefits management system 100. The user manuals can bestored in various formats to facilitate and simplify access by users.Such formats include, but are not limited to, plain text, formattedtext, word processor-specific format (e.g. MS Word, WordPerfect, etc),Adobe Acrobat, hypertext, HTML, etc. Accordingly, the user would becapable of conveniently obtaining the same information contained in theactual reference manuals directly from the computer. The prescriptionbenefits management system 100 can also be configured to automaticallyaccess necessary, or helper, applications to display both the usermanuals and the help pages.

The user can optionally access the status report menu 116. The statusreport menu 116 allows the user to obtain information regardingapprovals, denials, and other status data based on product orapplication. The information displayed on the status report menu 116 caninclude hyperlinks for information such as contract, carrier, client id,etc. When the hyperlinks are selected, the prescription benefitmanagement system 100 would automatically generate or retrieve theappropriate status report. The status report menu 116 can also includesearch fields that allow the user to enter certain criteria, such as aspecific date range, for which the report will be generated. The actualstatus report criteria can be pre-determined in the event the user doesnot wish to enter a date range. In such instances, the default periodcould be, for example, the most recent 24-hour period. Depending on theusers specific access level, the status report menu 116 can optionallyprovide an option to print the report generated. Furthermore, the usercan be given an option to select or change the particular client forwhich the report is being viewed.

According to one embodiment of the present invention, the prescriptionbenefit management system 100 is optionally configured to automaticallygenerate quarterly status reports for each client. Thus, unless a userrequires status information that is less than three months old, thequarterly status report can be automatically or manually retrieved.According to an optional embodiment of the present invention, thequarterly status report would contain information for all clients.Alternatively, the user can input specific criteria to identify one ormore clients. The status reports would then be generated for theidentified clients.

The user can select the view reference library menu 118 in order toexamine various documents used to support decisions made for aparticular case record. Such decision support document are typicallyauthored by users having administrative privileges. Non-administrativeusers are free to access and view documents stored in the referencelibrary, although they are unable to make any changes. The decisionsupport documents can be organized by product group and configured totake various forms. For example, one implemented document group containscoverage summary documents which describe a product and also describeprior authorization criteria and/or rationale necessary for supporting acoverage denial. Another type of decision support document is areference document which contains a list of citations referring toexternal reference articles and/or other publications that have beenused to support a particular coverage denial. Depending on the decisionbeing made, a product may include a coverage summary document, whileonly certain products will have an associated reference document. Ingeneral, all products will contain a coverage summary document while notall will require a reference document. When the user accesses the listof citations, hyper-text links can be used in order to retrieve theactual text or content of individual citations.

The release case menu 120 allows users to release a case record beingheld by another user. This is beneficial for preventing multiple editsto different copies of the original file. Typically, only administrativeusers are given the option to release a case record. This safeguardminimizes the number of users capable of incorporating changes to a caserecord, thus minimizing potential errors. For example, if a first useris currently viewing a case record, that case record is considered heldby the user. A copy of the information stored in the prescriptionbenefits management system 100 is displayed to the first user. If asecond user accesses the same case record, then another copy of the caserecord is retrieved and displayed to the second user. Both copiesreflect the original case record stored on the prescription benefitmanagement system 100. If both users were to make changes to the caserecord and simultaneously attempt to save the document, various errorscan occur. Furthermore, not all of the changes would be entered in thecase record. In order to avoid such mistakes, case records must first bereleased before changes can be implemented. Accordingly, if the seconduser is an administrative user, the second user would have the authorityto release the case record and close the copy being used by the firstuser so that changes can be made and appropriately saved to theprescription benefit management system 100.

According to one embodiment of the present invention, if a user accessesa case record, the prescription benefits management system 100 willautomatically provide an indication of whether the case record is beingheld or not. There are also situations wherein improper logout by a usercan cause a case record to remain open in the prescription benefitsmanagement system 100, although no users are currently accessing thecase record. In such situations, an administrator can access the caserecord and release it in order to clear the status.

The search for case menu 122 (e.g., search menu) allows a user to inputvarious search criteria to retrieve case records. Most users accessingthe prescription benefits management 100 will access the search menu 122in order to retrieve one or more desired case records. Upon accessingthe search menu 122, the user is presented with a search page which canbe pre-populated with certain search fields. The user would then inputone or more search terms in each search field in order to conduct thesearch. Because of its potentially significant and routine use, thesearch menu 122 can be made accessible throughout various menu levels inthe prescription benefits management system 100.

According to one embodiment of the present invention, the search pagegenerated by the search menu 122 can include an archive parameter. Whena user conducts a search, the prescription benefits management system100 examines the archive parameter to determine whether both historicaland current data should be retrieved. Typically, the archive parameteris left unselected. The time period containing current data can beoptionally defined using a pre-determined time range such as, forexample, 18-months. Thus, an archive search would access data that isolder than 18 months. This search can be conducted in conjunction with,or independent of, the current search. More particularly, the user wouldhave an option to search only current case records or search bothcurrent and archived case records. Once a search has been successfullyconducted, the prescription benefits management system 100 generates asearch results page containing a list of case records matching thesearch criteria. Furthermore, hyper-text links can be provided in orderto access selected case records directly from the list.

Once a user determines that a case record is relevant, the view casedetail menu 124 can be selected. A case activity detail page isgenerated to provide specific information for the selected case record.Depending on the users access level various paths may be followedsubsequent to displaying the case activity detail. Non-clinical (orexternal) users can be directed to limited options, while clinical (orexternal) users can be directed to a menu page having at least the samenumber of options as the non-clinical users. Clinical users will oftenbe administrators or employees of the organization operating theprescription benefits management system 100. According to one embodimentof the invention, the user can be presented with an inquiry menu 126containing the option to access multiple sub-menus such as, for example:review communications 128, review coverage criteria 132, review ofreasons for denial 138, display activity report 134, display coverageactivity summary, and review of reasons for denial 138.

The review communication menu 128 provides a list of all communicationitems that have occurred for the case record. Thus, all activityassociated with a particular case record and within a predeterminedactivity period will automatically be displayed. For example, eachactivity can be presented an entry that includes a header defining thetype of communication, the status of the communication, the start date,and the end date for the communication. A history of each communicationtype can also be presented to the user. While reviewing the list ofcommunication items, the user has an ability to review the details ofeach specific communication. Again, such a feature can optionally beimplemented using hyper-text links that will retrieve the actualcommunication record. Furthermore, the user can select the addcommunication menu 130 in order to generate a new communication entryfor a client or for a case record currently being viewed.

Administrative and clinical users also have access to the coveragecriteria menu 132. The coverage criteria menu 132 is preferably accessedwhile a user is viewing a case record. Each coverage criteria entry canoptionally consist of a question, answer, comment, and optionalsupplemental data field. The coverage criteria corresponds to a sequenceof questions and answers that has lead the prescription benefitsmanagement system 100 to render a particular decision regarding coveragefor a product or treatment. According to one embodiment of the presentinvention, only activities that have been denied coverage can bereviewed from this menu. Thus, if a claim for a particularproduct/treatment has been approved, users will not be able to reviewthe coverage criteria. It should be noted, however, that administrativeusers can be provided access to the coverage criteria even if theproduct/treatment has been approved in order to conduct administrativetasks. Users can optionally access the activity report menu 134 in orderto display all information pertaining to a particular activity. Forexample, the user can obtain information pertaining to the physician,the patient, the member, the coverage criteria, reasons for denial, etc.Once the user selects to view the activity report for a case record, thereport generated can subsequently be printed.

The coverage activity summary menu 136 provides the user with an abilityto view a custom breakdown of approvals, denials, and other status databy product and application. The report generated include data regardingthe client's organizational archive such as, the organization id, thecarrier, and the contract. Certain information, such as the contract andcarrier can optionally be in the form of hyper-text links that willaccess a report specific to either a particular contract or anaggregated carrier. According to one embodiment of the presentinvention, the user can be provided with a series of links that allowselection of a time period for which the reports are generated. Forexample, the links can identify periods which define the previous week,a rolling seven day period preceding the current day, etc. It should benoted that in such cases, the previous week can be defined as a fixedinterval from Sunday to Sunday, or Saturday to Saturday, etc. Thus, theprevious week and the rolling seven day period would, in certainsubstances, provide different date ranges. Furthermore, if a particulardate does not contain an activity, then the field will be empty.

According to one embodiment of the present invention, the coverageactivity summary can display a list of product rows and/or a list ofproduct category rows. For each product row, the corresponding columnscould include a tabulation of coverage approvals and coverage denialsfor each activity type (e.g., primary, renewal, appeal, administrativeoverride, clarification, etc.). Furthermore, since administrativeoverrides are never denied, the reports could be configured to onlydisplay a field which tabulates the coverage approvals. Cases that areeither open or pending are collectively identified as “work inprogress.” The reasons for denial menu 138 allows administrators andclinical users to determine why an activity has been denied coverage.This feature is only accessible when a user is currently viewing a caserecord.

According to one embodiment of the present invention, the case recordcan include a status indication that identifies whether an activity hasbeen denied coverage. When the user accesses this feature, a list ofreasons is generated. Each individual reason provides the user with anindication of where the explanation for denying the activity can befound. For example, if the reason for coverage denial is based onanswers to criteria questions, then an indication that the reason can befound from the “reason” table is provided. If the reason for coveragedenial is based on an override, then the details would be found in anactivity comments form. If the reason for coverage denial is based on anappeal then the details would be found in the appeal details form.

While reviewing the reasons for denying an activity, an administratorcan have various options. An administrative override can be performed tooverride denial of the activity. The administrative override couldoptionally be based on concrete, non-clinical criteria. The user canalso process an appeal of the coverage denial. In processing the appeal,the user can either override or uphold a primary denial based onclinical reasons. Typically, question and answer type criteria cannot beused to either uphold or override a primary coverage denial. Whenprocessing an appeal, the user may elect to change the product that isassociated with the current appeal by selecting the change drug menu144. One advantage of such a change is that a different product may beuseable for treating the same illness without resulting in denial of theparticular activity. For example, the user can enter the name of the newproduct as well as the eleven digit NDC code to enter the new product.The user can also elect to add an ICD9/diagnosis to the appeal byselecting the search for ICD9 menu 146. This feature performs a searchon the prescription benefit management system's ICD9 database to obtainmatching codes and descriptions for different products. Once satisfiedwith the appeal process, the user can elect to view the workflowundertaken during the review of an activity by selecting the view reviewmenu 148.

The user can also be directed from the view case details menu 124 to areview menu 150. The review menu 150 presents the user with an option toadd a review to the case or to unlock a particular case. In order to adda review, the user selects the add review menu 152 and is furtherpresented with an edit/view review menu 158. This allows the user toinitiate one of the two types of review processes, namely the appealprocess and the administrative override. In addition, the add review 152menu can provide the user with the option of generating an unclassifiedreview type which can be used to investigate a coverage denial based onmiscellaneous criteria. The user can also elect to unlock a case fromthe review menu 150. Typically, if changes are being made to a caserecord, the prescription benefits management system 100 will lock thecase record in order to prevent someone from simultaneously accessingthe same case record and making further edits. Accordingly, it should benoted that administrative privileges will often be necessary to unlock acase.

Once a case is unlocked, the user is presented with the changes menu 156wherein they can perform various changes to the case record. Forexample, the user can search for a specific doctor and/or change thecurrent doctor assigned to a particular patient by selecting thechange/search for doctor menu 160. The user can also generate lettersand correspondence to be sent out to the patients by selecting thegenerate letters menu 162. By selecting the lock case menu 164, the caserecord can be locked in order to prevent access by, for example,non-administrative personnel. Changes to the patient's information canalso be performed by selecting the change patient info menu 166. Suchchanges can correspond to, for example, the patients name, address, andother personal data.

Turning now to FIG. 2, a flow chart is illustrated for showing the stepsperformed to gain access to the prescription benefits management system100. The process begins at step S200, where the user would initiate aconnection to the prescription benefits management system 100. At stepS210, the user accesses the login screen 110. At step S212 the userenters the appropriate login information. As previously, discussed suchinformation can include, for example, a username/password combination,an account number/password combination, etc. Regardless of thecombination used, the values can be automatically assigned or selectedby the user. If the login information entered by the user is not validas determined at step S214, then control passes to step S218. Whilevalidating the log in information, data is accessed from a clientprofile database in order to verify the existence of the users account.The client profile database can include various information about theclient including, for example, personal information about members (e.g.,employers) and/or patients.

At step S218, a counter is initiated to determine how many attempts havebeen made to access the prescription benefits management system. Amaximum number of attempts can be predefined in order to determine if auser may be attempting to gain unauthorized access to the prescriptionbenefits management system 100. The counter can be incremented by oneeach time an unsuccessful login attempt is made. Thus, at step 218 ifthe number of attempts to access the prescription benefits managementsystem 100 exceeds the predefined threshold value, then control passesto step S220. At step S220 appropriate restrictions are internallygenerated to suspend the user's account. In this instance, suspensioncan be based on, for example, the username for which the password hasbeen improperly entered, or vice versa. Various other steps can be takensuch as, for example, asking the user to answer a question for which theanswer is known by the prescription benefits management system 100. Theuser can also be instructed to contact customer service to resolve theproblem. In addition, a live (e.g., interactive) dialogue can optionallybe initiated online with the customer service representative. If thenumber of attempts has not exceeded the threshold value, then controlreturns to step S212, where the user is again prompted to enter thelogin information.

At step S216, the user is prompted to enter an account information. Theaccount information can correspond to data which uniquely identifies aclient and/or particular patient within the prescription benefitsmanagement system 100. At step S222 it is determined whether the accountinformation is valid. If the account information is not valid controlpasses to step S226, where an error message is displayed. Otherwise ifthe account information is valid then control passes to step S224 wherethe client information is displayed to the user.

According to one embodiment of the present invention, by providing aseparate account information, the user can also be given the ability toaccess information outside of the prescription benefit management system100. More particularly, the displayed client account can include clientspecific home pages with hot links and other personalized information.The hot links and home page addresses can re-direct the user toinformation stored outside the prescription benefits management system100 such, as employer home pages and databases, warning and informationregarding certain products, etc. Furthermore, while validating theaccount information, a message database containing comments and dataspecific to the client information is accessed to determine whether ornot the account is valid. After the client information has beendisplayed, the authorization process is terminated at step S228.

FIG. 3 illustrates additional details pertaining to the steps performedwhen obtaining assistance directly through the prescription benefitsmanagement system 100. The process begins at step S300 wherein, forexample, the user would have selected the help and user manuals menu114. At step S310, the user is prompted to provide an indication ofwhether they would like to access either the user manual or help on aparticular topic. If a user would like help, then control passes to stepS312 where the user is prompted to input various search terms. This canbe in the form of a query page containing predefined search fields, orthe user can be given an opportunity to conduct an advanced (or boolean)query. Alternatively, the user can be given an option to quickly viewthe help topics associated with the current page or menu level beingaccessed. Once the search terms have been entered and the search isinitiated, the prescription benefits management system 100 retrieves alist of help topics at step S314. The list of help topics can be in theform of hypertext links that can be selected by the user. Once the linkfor a particular help topic is selected, a help page is generate at stepS316 for viewing. After the user has finished examining the desired helppages, the process can be terminated. Alternatively, the user may beredirected to step S310 in order to conduct a new search or to viewactual manual topics.

There are occasions, however, when the user will require more detailedand technical information than that available in the help pages. In suchoccasions, the user will typically elect to access the manuals at stepS310. At step S318, the user is prompted to input the topics they wouldlike to view in the user manuals. At step S320, the prescriptionbenefits management system 100 conducts a search of available databasesin order to retrieve information from the manuals regarding the searchtopics. At step S322, preview pages are generated for topics that havebeen retrieved during the search. The preview pages can correspond topredetermined amounts of data presented to the user in the form of abrief text file or a single HTML page. The user also has an option toview the entire manual, and can be prompted to do so at step S324. Ifthe user does not desire to view the entire manual, then the previewpages continue to be generated at step S326. The process concludes whenthe user has viewed enough of the preview pages.

According to the disclosed embodiment of the invention, if the userwould like to see the entire manual, then at step S328, it is determinedwhether a viewer is available for appropriately displaying the entiremanual. Such a viewer can correspond to, for example, the Adobe Acrobat™viewer or an appropriate word processing software. If an appropriateviewer is available, then control passes to step S330 where a formattedversion of the manual is loaded and displayed. Otherwise, if there is noappropriate viewer available, then control passes to step S326 where thepreview pages continue to be generated. Optionally, the user may beallowed to view the entire manual in HTML format using a conventionalweb browser. Once the user has finished viewing the manual, the processends at step S332.

Turning to FIG. 4, the details for releasing a case record will now bedescribed. The process begins at step S400. At step S410, the userenters or selects a case ID number. This can also correspond to asituation where a list of case records has been presented to the user asa result of a search request. Upon selecting a case or entering the caseID number, it is determined if the case record is currently being heldat step S412. If the case record is not being held, then the releaseprocess terminates. If the case record is being held, the case summaryis displayed at step S414. At step S416 the user is prompted to indicatewhether the case record should be released. If the case record does nothave to be released, then the process terminates. If the case recordwill be released, then at step S418 it is determined whether the user isan employee of the organization implementing the prescription benefitsmanagement system 100 or an outside client.

If the user is an employee, then control passes the step S422 where thecase record is released. Otherwise, if the user is an outside client,than control passes to step S420 where additional criteria must bedetermined. At step S420, it is determined whether the case record isbeing held by a client. If the case record is being held by a client,then it is released at step S422. The prescription benefits managementsystem 100 can optionally verify that the case record should be releasedat step S426 prior to actually releasing the case record. If theverification process results in a determination that the case recordshould not be released, then the process would automatically terminate.If at step S420, it is determined that the case record is not being heldby a client, then at step S424 the user is given an indication that thecase record cannot be released and the process terminates. This cancorrespond, for example, to a situation where the case record is beingheld by an employee who has administrative or higher level access rightsthan the client or user. After the case record has been released, theprocess ends at step S428.

FIG. 5 illustrates the steps performed when conducting a search for caserecords. The process begins at step S500. At step S510, the useraccesses the search menu 122. In response, a search request form isgenerated at step S512. The user then inputs desired search parametersat step S514. At step S516, the user is optionally prompted to indicatewhether the search a request should be submitted. If the search requestwill not be submitted, then control passes to control block B andultimately to step S542 where the search is abandoned. If the user wouldlike to submit the search request, the prescription benefits managementsystem 100 determines if any search parameters have been entered in thesearch request form. The search parameters can include, withoutlimitation, a case ID; a member ID; a patient's last name, first name,or date of birth; unlocked, or available cases; cases that requiresigning off; etc. If no search parameters have been entered, controlpasses to step S520 where the user is prompted to input at least onesearch parameter. Control then passes to block A and returns to stepS512 where a new search request form is generated. Alternatively, blockA can redirect the user to step S514.

If search parameters have been entered into the search request form,their validity is checked at step S522. For example, if a numeric searchparameter such as a client account number is entered in a text fieldsuch as a patient name, then the search parameter would be invalid. Ifany of the search parameters are invalid, then control passes to stepS524 where the user is informed that one or more search parameters areinvalid. The invalid search parameters can optionally be displayed atthis point. Control then passes to block A and returns to step S512 (oroptionally step S514) where a new search research form is generated.Upon generating the new search request form, it is possible to maintainthe valid search parameter so that the user does not have to reenterthem. If the search parameters are valid then control passes to stepS526.

The user is prompted to indicate whether a standard search should beconducted. If a standard search will be conducted, then control passesto step S530 where active files are searched. As previously discussed,the active files can include, for example, files from the last year, 18months, 2 years, etc. If the user does not wish to conduct a standardsearch, then an extended search will be conducted. According to oneexemplary embodiment of the present invention, in order to conduct thestandard search, the archived files are first searched at step S528.Once the archived files have been searched, control passes to step S530,where the active files are also searched. Thus, the extended searchwould comprise both active and archived files.

At step S532, it is determined whether the search has been successfullyconducted. If an error has occurred or the search was abruptlyterminated, then control passes to step S534. An error page is generatedand presented to the user to indicate the problems that were encounteredduring the search. Control then passes to block B and ultimately to stepS542 where the search is abandoned. If the search was successfullyconducted then control passes to step S536. It is then determined if anyresults were obtain based on the submitted search criteria. If resultswere not obtained, then the user can be redirected to step S512 where anew search request form can be generated. Otherwise, a search resultspage is generated at step S538. At step S540, the user can select a caserecord and view its details. Once the user has concluded viewing of thecase record, the process is terminated at step S544. Optionally, theuser can be redirected to the search results page (step S538) in orderto view one or more additional case records.

FIG. 6 illustrates the steps performed when details of a case recordmust be viewed. The process begins at step S600. At step S610, the userselects a particular case record. This can be done by either inputtingthe case number or selecting a case record that has been presented as aresult of a search request. At step S612, it is determined if casedetails are available for the desired case. If no case details areavailable then an error page is generated at step S614 and presented tothe user. The process is then terminated. If a case details areavailable, then the most recent case activity is retrieved at step S616.At step S618, it is determined whether an activity record is currentlyavailable for the selected case record. The activity record correspondsto a record of any activities that have been conducted on the caserecord such as, for example, a communication, a review, a change inphysician, etc. If no activity record is available, then an error pageis again generated at step S614. If an activity record is available,then a new page is presented to the user at step S620 in order todisplay the details of the case record. The process would then terminateat step S622 after the user has viewed the details of the case record.

FIG. 7 is a flowchart illustrating the steps performed when reviewingthe coverage criteria 132 for a particular prescription claim. Thereview process would begin at step S700. The user would select a case toreview at step S710. At step S712, the prescription benefits managementsystem 100 determines if any communication records are available for thecase record. If there are no communication records available, then anerror page is generated at step S714 and presented to the user. Theprocess would then end at step S728. If communication records areavailable the user is prompted to indicate whether all communicationsshould be shown at step S716. If the user does not want to view all thecommunication records, then control to step S722. This corresponds to asituation wherein the user may only be interested in writtencorrespondences that have been sent out to the patient, or possiblywhether any appeals have been conducted. Accordingly, the user wouldselect the specific sets of communication records that they would liketo view at step S722. At step S724, the selected communication recordsare retrieved and displayed. Otherwise, all the communication recordsare retrieved at step S718. At step S720, a communication history pagedetailing the different communications and their dates is generated andpresented to the user. The user can then optionally access the casedetail page at step S726 in order to obtain further informationregarding the case record. The process would end at step S728 after theuser has finished reviewing the communication records and/or the casedetail.

FIG. 8 illustrates the steps performed to review coverage criteria for aprescription claim. The process begins at step S800. The user wouldinvoke, or request, the review process at step S810. At step S812, theprescription benefits management system 100 retrieves various reviewcriteria for the current activity. At step S814, it is determinedwhether the retrieval process was successful in obtaining matchingrecords. If no records were retrieved, then an error page is generatedat step S816 and presented to the user. Otherwise, a criteria page isgenerated and presented to the user at step S818. At step S820, the userreviews the chart for specified criteria. At step S822, the user canoptionally dismiss the chart and terminate the process at step S824.

FIG. 9 illustrates the steps performed to review the status of a case116. The process begins at step S900. At S910 the user requests a statusreport for a particular case. At step S912, a list of report links isgenerated and presented to the user. At S914, the user selects the linkto a report for which they would like to see the status. At step S916,the prescription benefits management system 100 generates a full reportbased on the report link selected by the user. As the report is beinggenerated if any errors are encountered at step S918, then an error pageis generated at step S920 and presented to the user. The process wouldthen end. If the report was successfully generated, then the actualreport is displayed to the user at step S922. At this point, the usercan optionally be given an ability to print the report at step S924.Alternatively, the user can request that a report be generated for adifferent client, carrier, etc at step S926. Furthermore, the user canchange the reporting period at step S928. Control would then return tostep S912 where a new list of report links would be generated. Once theuser is satisfied with review of the report, the process ends at stepS930.

As can be appreciated, proper operation and maintenance of theprescription benefits management system 100 can require significantinput and administrative control. In order to accomplish this, and tosimultaneously ensure smooth operation of the system, certain users canbe given high level administrative, or superuser, access. Such accesswould allow the user to create, edit, and manage data within theprescription benefits management system 100.

Referring to FIG. 10, an exemplary administrative menu 180 andcorresponding administrative functions are illustrated. Theadministrative menu 180 can be accessed by certain users in order toperform maintenance or special operations on the prescription benefitsmanagement system 100. As shown in FIG. 10, the exemplary administrativemenu 180 branches out by means of two submenus. A user registration menu182 allows the administrator to manage registration and restrictions onnew users to the system. For example, the administrator would have theability to add, edit, or delete users through menu 184. Menu 186 wouldallow the administrator to configure the user and with particular accessrights. Menu 188 would allow the administrator to quickly search for andreview information pertaining to a particular user. The administratorcan also access a client registration menu 190. From the clientregistration menu 190, the administrator would able to add, delete, oredit client information through menu 192. Menu 194 would allow theadministrator to configure the access rights of the client. Finally,menu 196 would allow the administrator to search for a particular clientin order to review and/or modify their information.

FIG. 11 illustrates an exemplary implementation of the present inventionfor managing multiple prescription benefits programs. According to theexemplary embodiment, the prescription benefits management system 100 isimplemented as a rules-based coverage management system (CMWS), aspreviously discussed. The prescription benefits management system 100includes appropriate database management systems (not shown) for storingcase records and associated information. External or internal storagedevices can also be used if a large number of case records exist, or toprovide capacity for expanding the number of case records available.

According to the disclosed embodiment of the invention, the prescriptionbenefits management system 100 is used for managing prescriptionbenefits from one or more healthcare providers 102. The healthcareprovider 102, in turn, provides services to multiple employers such as,for example, clients 104. As can be appreciated, each healthcareprovider 102 can offer multiple prescription benefits plans to eachclient 104. The clients 104 ultimately offer the prescription benefitsplans their employees (e.g., patients 106) as part of an employmentpackage. Case records are created for each patient 106, depending onvarious factors, including the selected prescription benefits plan, thetype of treatment and/or product used by the patient, the number andtype of communications with the patient, etc.

Each healthcare provider 102 is capable of establishing a communicationlink with the prescription benefits management system 100. Thecommunication link can be established using various types of networksincluding, open networks, closed networks, the internet, direct dialnetworks, etc. A customer service representative, or appropriatepersonnel, can initiate contact with the prescription benefitsmanagement system 100 in order to review, create, and/or delete caserecords. Administrators of the prescription benefits management system100 can optionally exercise control over the type of data being accessedand/or modified through the communication channel. This can beimplemented using various methods including, for example, apassword/access right system. Thus, a certain degree of control can bemaintained over the amount and type of data accessed.

One optional embodiment of the present invention allows various levelsof remote access to various external users. For example, anrepresentative of the healthcare provider 102 could be given access toreview, modify, and/or delete various information within a case record.A client 104 could be given access to view case records for theirpatients 106. Each patient 106 could be given access to view certaindata contained in their case record. As can be appreciated, thehealthcare providers 102, the clients 104, and the patients 106 haveaccess to computers, terminals, and/or appropriate communication devicesfor accessing the prescription benefits management system 100.Additionally, the prescription benefits management system 100 can beconfigured to establish multiple communication channels simultaneously.

Major objectives and advantages of the present invention are convenienceand cost reduction (where appropriate, safe, and effective). Theprescription benefits management system of the present invention standsto benefit healthcare providers, pharmacies, and patients. Moreparticularly, healthcare providers can perform functions necessary tomanage prescription benefit plans more efficiently, thereby reducing thecost of coverage and improving the number and quality of productsavailable to patients. Certain tasks, such as appeals and reviews can beperformed quickly and efficiently while records of the transactions areautomatically generated and maintained. For example, upon reviewing aprescription coverage denial, various criteria could support a reversalof the original denial. All the information and documentation used tosupport the reversal would be automatically stored in the system.Furthermore, certain correspondence could be immediately generated fordelivery to the patient. Thus, patients receive several additionalbenefits. The time for reviewing and reversing appeals can be greatlyreduced. Throughout the review process, correspondence can be directedto the patient to indicate the status of an appeal or review.

The present invention provides further functions that allow a user toconveniently manage a prescription benefits program. These abilitiesinclude, but are not limited to: browsing coverage related information,aggregating coverage activities summary, administering appealprocedures, and generating related correspondence. The present inventionis capable of administering coverage reviews and generating relatedcorrespondence, tracking and managing contacts/communications withmembers, physicians, and pharmacist, and creating and maintainingcoverage criteria. Additionally the prescription benefits managementsystem can optionally be remotely accessed by patients and other usersto obtain and review information regarding their prescription benefitsprogram.

The many features and advantages of the invention are apparent from thedetailed specification, and thus, it is intended by the appended claimsto cover all such features and advantages of the invention which fallwithin the true spirit and scope of the invention. Further, sincenumerous modifications and variations will readily occur to thoseskilled in the art, it is not desired to limit the invention to theexact construction and operation illustrated and described, andaccordingly, all suitable modifications and equivalents may be resortedto, falling within the scope of the invention.

1. A method of managing prescription benefits offered by a plurality ofproviders of prescription benefits, comprising: storing prescriptionbenefit case records in a prescription benefits management computersystem for users at least one of receiving or administrating one of aplurality of prescription benefits coverage plans from at least one ofthe plurality of providers of prescription benefits, said prescriptionbenefit case records comprising information regarding patients andprescription coverage activities including at least one of a type oftreatment associated with the prescription benefits coverage,pharmaceutical product used by the patient when present, and a numberand type of communications with the patient associated with theprescription benefits coverage, accessible to the users responsive tothe one of the plurality of prescription benefits coverage plans;providing access to the plurality of prescription benefits coverageplans from the at least one of the plurality of providers ofprescription benefits using said prescription benefits managementcomputer system to respective plurality of providers of prescriptionbenefits over one or more electronic communication networks; receiving arequest to access said prescription benefits management computer systemfrom the user of at least one of the plurality of providers ofprescription benefits from remote locations via one or more electroniccommunication networks, wherein access to said prescription benefitsmanagement computer system is provided based on at least one of aplurality of preconfigured access rights corresponding to at least oneof the user and the provider of the prescription benefits offeredthrough the one of the plurality of prescription benefits coverage plansfrom the at least one the plurality of providers of prescriptionbenefits; selecting at least one of a plurality of prescription coverageactivities contained in said prescription benefit case recordscorresponding to the prescription benefits coverage plan; conducting aninquiry on said prescription benefit case records to view and reviewingselected prescription coverage activities contained in said prescriptionbenefit case records responsive to the request from the user, whereinthe inquiry to view and review the selected prescription coverageactivities further comprises displaying a plurality of options to accesssaid prescription coverage activities for the user based on the at leastone of a plurality of preconfigured access rights, and selecting atleast one of the plurality of options to access said prescriptioncoverage activities, reviewing details of the prescription coverages,and at least one of overriding the displayed prescription coverage basedon one or more clinical and prescription criteria, replacing an originalprescription product with a substitute prescription product that iscovered by a prescription benefit plan associated with the case record,and appealing the prescription coverage denial based on clinical reasonsin response to receiving a request from the user, selecting a newprescription benefit case record for prescription benefits, determiningwhether the new case record is currently being viewed by a second user,receiving instructions from user to release the new case record if thenew case record is currently being viewed by the second user,determining whether the user is an employee of at least oneorganization, offering the one of the plurality of prescription benefitscoverage plans from the at least one of the plurality of providers ofprescription benefits, implementing the prescription benefits managementcomputer system, releasing the new prescription case record without thesecond user's authorization if the second user is at least one of anemployee and a client of the organization implementing the prescriptionbenefits management computer system, and closing said prescriptionbenefit case records.
 2. The method of claim 1 further comprising a stepof accessing at least one of a help manual and a user manual stored inelectronic form on the prescription benefit management computer systemto obtain instructions for assisting in operating the system.
 3. Themethod of claim 1, further comprising a step of displaying a statusreport identifying at least approvals/denials of claims for prescriptioncoverage.
 4. The method of claim 1, further comprising a step of viewinga reference library containing a collection of documents used to supportdecisions made on a case record.
 5. The method of claim 1, wherein thestep of accessing further comprises a step of displaying case activitydetails corresponding to either specific information on the patient orprescription coverage activities for the patient, after the case recordhas been accessed.
 6. The method of claim 1, wherein the step ofconducting further comprises the steps: inquiring on communication itemsrelating to the case record; and displaying details of all communicationitems that have occurred in the case record, including at least themedium and direction of each communication item.
 7. The method of claim1, further comprising a step of reviewing a coverage criteria for thecase record subsequent to the step of conducting an inquiry, wherein thecoverage criteria comprises information which led to a particulardecision on the case record.
 8. The method of claim 1, furthercomprising a step of displaying an activity report containing allprescription coverage activities and reference data for the case record.9. The method of claim 1, further comprising a step of displayingcoverage activity details for the selected case record, the coverageactivity details including at least a list of products, a list ofcoverage products, and a list of product categories.
 10. The method ofclaim 1, wherein the selected case record contains at least oneprescription coverage denial, and further comprising the steps:displaying one or more reasons for each coverage denial; and reviewingdetails of the displayed reasons.
 11. The method of claim 10, whereinthe case record is being reviewed by an administrator and furthercomprising a step of overriding the displayed coverage denial based onone or more clinical criteria.
 12. The method of claim 10, furthercomprising a step of processing appealing the coverage denial based onclinical reasons, and wherein the coverage denial may be reversed orupheld.
 13. The method of claim 12, wherein the step of processing anappeal further includes a step of replacing an original prescriptionproduct with a substitute prescription product that is covered by aprescription benefit plan associated with the case record.
 14. Themethod of claim 12, wherein the step of processing an appeal furthercomprises the step of viewing entries generated by prior reviews of atleast one of the case record and any coverage denials thereof.
 15. Themethod of claim 1, further comprising a step of creating a new reviewfor the selected case record, and entering prescription coverageactivity information for the case record.
 16. The method of claim 1,wherein an administrator is accessing the case record, and furthercomprising the steps: changing a security status of the selected caserecord from a locked status to an unlocked status; and entering changesto one or more case parameters.
 17. The method of claim 16, furthercomprising a step of generating correspondence to be sent to a patientidentified in the case record.
 18. The method of claim 1, furthercomprising a step of automatically generating status reports for one ormore clients at predetermined intervals.
 19. The method of claim 1,further comprising a step of automatically generating and maintaining arecord of all transactions performed while using the prescriptionbenefits management computer system.
 20. The method of claim 1, furthercomprising providing the user access to said prescription benefitsmanagement computer system based on authority to at least one of: view,change, modify, and create information stored in the prescriptionbenefits management computer system.
 21. The method of claim 1, whereinthe preconfigured access rights comprises authority for anadministrative user of the at least one of the plurality of providers ofthe prescription benefits, and wherein said method further comprisesproviding access to the administrative user of the at least one of theplurality of providers of the prescription benefits to change, modify,and create information stored in the prescription benefits managementcomputer system.
 22. The method of claim 21, wherein the preconfiguredaccess rights comprises authority for a staff member of the prescriptionbenefits management computer system, and wherein said method furthercomprises providing access to the staff member to view, change, andmodify information stored in the prescription benefits managementcomputer system.
 23. The method of claim 1, further comprising:providing the at least one of the plurality of prescription benefitsproviders authority to view information stored in the prescriptionbenefits management computer system, and providing the at least one ofthe plurality of prescription benefits providers authority to respond toquestions, and providing the at least one of the plurality ofprescription benefits providers authority to enter information intofauns for storing in the prescription benefits management computersystem.
 24. The method of claim 1, wherein the preconfigured accessrights comprises authority for an administrative user of the at leastone of the plurality of providers of the prescription benefits, andwherein said method further comprises providing access to theadministrative user to modify at least one of the plurality of caserecords of a member of the at least one of the plurality of providers ofthe prescription benefits stored in said prescription managementcomputer system without the at least one user of the at least one of theplurality of providers releasing the at least one of the case records.25. The method of claim 1, wherein the preconfigured access rightscomprises authority for an administrative user of the at least one ofthe plurality of providers of the prescription benefits, and whereinsaid method further comprises providing access to the administrativeuser to release at least one of the plurality of case records of amember of the at least one of the plurality of providers of theprescription benefits stored in said prescription management computersystem held open by the at least one user of the at least one of theplurality of providers.
 26. The method of claim 1, wherein thepreconfigured access rights comprises authority for an administrativeuser of the at least one of the plurality of providers of theprescription benefits, and wherein said method further comprisesproviding access to the administrative user to modify coverage criteriainformation, wherein the coverage criteria information comprises adecision regarding coverage for at least one of a product and treatment.27. The method of claim 1, further comprising displaying the activityreport for a case record comprising user identifier, carrierinformation, contract information, physician, patient, member, coveragecriteria, and reasons for denial.
 28. The method of claim 1, furthercomprising: receiving at least one search term from the user to searchfor at least one predetermined case record using a search parameter pagegenerated by the prescription benefit management computer system,wherein the search parameter page includes an archive parameter; andconducting a search for the at least one predetermined case record usingthe search parameter page generated by the prescription benefitmanagement computer system for the user.
 29. The method of claim 28,further comprising upon retrieving multiple case records from thesearch: selecting at least one desired case record for review by saidprescription benefit administrator, automatically capturingidentification data from the at least one desired case record by saidprescription benefit management computer system, conducting at least onesubsequent case record specific search by said prescription benefitadministrator, and filtering the at least one subsequent case recordspecific search results with respect to the at least one selected caserecord using the identification data by said prescription benefitmanagement computer system.
 30. A system for managing prescriptionbenefits offered by a plurality of providers of prescription benefits,comprising: a prescription benefits management computer system, forstoring prescription benefit case records for patients receiving one ofa plurality of prescription benefits coverage for the plurality ofproviders of prescription benefits, said prescription benefit caserecords comprising information regarding the patients and prescriptioncoverage activities including at least one of a type of treatmentassociated with the prescription benefits coverage, pharmaceuticalproduct used by the patient when present, and a number and type ofcommunications with the patient associated with the prescriptionbenefits coverage, pharmaceutical product used by the patient whenpresent, and a number and type of communications with the patientassociated with the prescription benefits coverage, accessible to thepatient responsive to the one of the plurality of prescription benefitscoverage plans; a communication device operatively coupled to saidprescription benefits management computer system for providing access tothe plurality of prescription benefits coverage plans from the at leastone of the plurality of providers of prescription benefits using saidprescription benefits management computer system to respective pluralityof providers of prescription benefits over one or more electroniccommunication networks; and said prescription benefits managementcomputer system for receiving a request to access said prescriptionbenefits management computer system from a user of at least one of theplurality of providers of prescription benefits utilizing at least oneuser computer from remote locations via said one or more electroniccommunication networks, wherein access to said prescription benefitsmanagement computer system is provided based on at least one of aplurality of preconfigured access right corresponding to at least one ofthe user and the provider of the prescription benefits offered throughthe one of the plurality of prescription benefits coverage plans fromthe at least one of the plurality of providers of prescription benefits;said prescription benefits management computer system being configuredto allow users to: select at least one of a plurality of prescriptioncoverage activities contained in said prescription benefit case recordscorresponding to the prescription benefits coverage plan; conduct aninquiry on said prescription benefit case records to view and reviewselected prescription coverage activities contained in said prescriptionbenefit case records responsive to the request from the user, whereinthe inquiry to view and review the selected prescription coverageactivities further comprises displaying a plurality of options to accesssaid prescription coverage activities for the patient based on the atleast one of a plurality of preconfigured access right, and selecting atleast one of the plurality of options to access said prescriptioncoverage activities, display one or more reasons for each prescriptioncoverage, and reviewing details of the displayed reasons, and at leastone of overriding the displayed prescription coverage denial based onone or more clinical and prescription criteria, replacing an originalprescription product with a substitute prescription product that iscovered by a prescription benefit plan associated with the case record,and appealing the prescription coverage denial based on clinical reasonsin response to receiving a request from a user, select a newprescription benefit case record for prescription benefits, determinewhether the new case record is currently being viewed by a second user,receive instructions from user to release the new case record if the newcase record is currently being viewed by the second user, determinewhether the user is an employee of at least one organization, offeringthe one of the plurality of prescription benefits coverage plans fromthe at least one of the plurality of providers of prescription benefits,implementing the prescription benefits management computer system,release the new prescription case record without the second user'sauthorization if the second user is at least one of an employee and aclient of the organization implementing the prescription benefitsmanagement computer system, modify information contained in theprescription benefit case record, and close said prescription benefitcase records.
 31. A method of managing prescription benefits offered bya plurality of providers of prescription benefits, comprising: storingprescription benefit case records in at least a prescription benefitsmanagement computer system for users receiving and/or administrating oneof a plurality of prescription benefits coverage-plans from at least oneof the plurality of providers of prescription benefits; providing accessto the plurality of prescription benefits coverage plans from the atleast one of the plurality of providers of prescription benefits usingsaid prescription benefits management computer system to respectiveplurality of providers of prescription benefits over one or moreelectronic communication networks; receiving a request to access saidprescription benefits management computer system from a user of at leastone of the plurality of providers of prescription benefits from remotelocations via one or more electronic communication networks, whereinaccess to said prescription benefits management computer system isprovided based on at least one of a plurality of preconfigured accessright corresponding to at least one of the user and the provider of theprescription benefits offered through the one of the plurality ofprescription benefits coverage plans from the at least one of theplurality of providers of prescription benefits; selecting at least oneof a plurality of prescription coverage activities contained in saidprescription benefit case records corresponding to the prescriptionbenefits coverage plan; conducting an inquiry on said prescriptionbenefit case records to view and reviewing selected prescriptioncoverage activities contained in said prescription benefit case recordsresponsive to the request from the user, wherein the inquiry to view andreview the selected prescription coverage activities further comprisesdisplaying a plurality of options to access said prescription coverageactivities for the at least one patient based on the at least one of aplurality of preconfigured access rights, and selecting at least one ofthe plurality of options to access said prescription coverageactivities, generating one or more reasons for each prescriptioncoverage, and reviewing details of the displayed reasons, and at leastone of overriding the displayed prescription coverage denial based onone or more clinical and prescription criteria, replacing an originalprescription product with a substitute prescription product that iscovered by a prescription benefit plan associated with the case record,and appealing the prescription coverage denial based on clinical reasonsin response to receiving a request from the user, selecting a newprescription benefit case record for prescription benefits, determiningwhether the new case record is currently being viewed by a second user,releasing the new prescription case record without the second user'sauthorization when the user is determined to be the a clinical user,modifying information contained in the prescription benefit case record,and closing said prescription benefit case records.